ATTACHMENT 1 - SELF –DECLARATION SELF DECLARATION COVID – 19 (to be delivered to the air carrier - write in block letters) THE UNDERSIGNED (LAST NAME AND FIRST NAME) NATIONALITY , BORN IN ON WITH PASSPORT/DOCUMENT N.. ISSUED ON BY RESIDENT______________________ DECLARES UNDER ITS OWN LIABILITY, PURSUANT TO THE REGULATION IN FORCE, AS FOLLOWS: 1) Not to be affected by COVID-19 or not to be subjected to a mandatory quarantine period of at least 14 days; 2) Not to be currently suffering from fever with a temperature above 37,5° C; 3) Not to accuse at the moment persistent cough, difficulty breathing, cold, sore throat, headache, severe weakness (tiredness), decrease or loss of smell/taste, diarrhea; 4) Not having had close contacts with person affected by COVID-19 since two days before the occurrence of symptoms and up to 14 days after the occurrence of the symptoms. I also undertake to inform the air carrier and Local Health Authority of any possible occurrence of above mentioned symptoms arising within eight days of disembarkation from the aircraft. In order to allow the traceability of the undersigned in the following 14 days from the arrival in Italy, here below I report my residential address /telephone/mobile number /e-mail account CITY , PROVINCE ADDRESS HOUSE NUMBER TELEPHONE/MOBILE Date and place : ZIP CODE e-mail , Legible signature of the declarant
